On the Need to Treat Endothelial Dysfunction in Patients With ACS and COVID-19 – The Cardiology Advisor

Therapies which improve endothelial dysfunction should be considered for the treatment of patients with coronavirus disease 2019 (COVID-19) and acute coronary syndrome (ACS), according to Study results published in Clinical Research in Cardiology.

Patients with angiographically confirmed ACS who tested positive (n=45) or negative (n=76) for COVID-19 and were treated across 17 hospitals in Italy, Spain, and Switzerland between February 19 and April 9 2020 were enrolled.

Of patients who tested positive for COVID-19, 0.96% had ACS. Among patients with COVID-19 and ACS, 60.0% had ST-segment elevation and 40.0% had non-ST-segment elevation. Single vessel disease was observed in 55.6% of these patients. All patients with ACS received a percutaneous coronary stent.

At baseline, patients with ACS who were positive vs negative for COVID-19 had higher rates of dyspnea (51.1% vs 19.7%, respectively; P <.001) and atrial hypertension (80.0% vs 51.3%, respectively; P =.002).

At study conclusion, mortality rates for patients with COVID-19 and ACS was 3 times higher than for patients with ACS alone (27.3% vs 8.9%, respectively; P =.004). Patients with ACS with ST-elevation and with vs without COVID-19 and had higher mortality rates (33.3% vs 9.3%, respectively; P =.024).

Of patients with ACS who died from COVID-19 complications, 75% had multiple organ systems involvement, indicative of vascular damage. Patients with COVID-19 and ACS who died vs survived had elevated troponin (factor increase in upper limit of normal [ULN]: 323.00 vs 65.00, respectively; P =.014) and brain natriuretic peptide (factor increase in ULN: 113.23 vs 2.00, respectively; P =.023), and reduced left ventricular ejection fraction (34.39.5% vs 45.310.3%, respectively; P =.003).

Study limitations includes the low incidence of ACS among patients positive for COVID-19 which may indicate that not angiography was not conducted on all patients with ST- or non-ST-segment elevation, so that coronary damage may have been overlooked during hospitalization for coronavirus infection.

[E]ndotheliitis in COVID-19 might affect various vascular beds thereby increasing the susceptibility for thromboembolic and septic complications or multi-organ-failure. Thus, myocardial ischemia due to ACS might be even aggravated by COVID-19 induced generalized microvascular dysfunction and systemic vascular damage leading to severe heart failure with unfavorable outcomes, noted the study authors. Therefore, in addition to a guideline-directed ACS management, therapies to improve endothelial dysfunction might be considered in patients with COVID-19.

Reference

Cammann V L, Szawan K A, DAscenzo F, et al. Outcomes of acute coronary syndromes in coronavirus disease 2019. [published online September 19, 2020] Clin Res Cardiol. doi:10.1007/s00392-020-01742-6

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On the Need to Treat Endothelial Dysfunction in Patients With ACS and COVID-19 - The Cardiology Advisor